Medical Therapy
Medical therapy of the brow and periorbital area requires a short discussion. Botulinum toxin (BOTOX®) is useful in temporarily paralyzing the corrugator supercilii muscles and portions of the orbicularis oculi muscles. In individuals with little skin excess and few rhytides at rest, this is excellent therapy until the patient is ready for and requires a true brow lift procedure.
Periorbital rejuvenation using lasers is largely one of tightening the periorbital skin to some degree; it has little effect on subcutaneous fat or any long-term effect on brow posture.
Surgical Therapy
Consider many adjunctive procedures (eg, canthopexy, [1] upper and lower eyelid blepharoplasty, laser resurfacing, midface lift) at the time of brow lift to rejuvenate the periorbital area. Periorbital rejuvenation is a vast topic; this article only discusses brow lift.
Preoperative Details
Prepare an initial analysis and surgical plan for all patients.
Assess true brow ptosis and symmetry with the patient in an upright posture with the frontalis muscle relaxed. See the images below.
Preoperative photograph demonstrating a young female patient with marked frown lines and congested appearance of the interbrow area with marked brow ptosis.
Preoperative view of a patient with brow ptosis, marked actinic skin damage, and thin upper lip.
Ascertain the amount of correction of upper eyelid skin excess with proper brow positioning and accurately predict the need for adjunctive upper eyelid blepharoplasty or skin tightening with laser.
If concurrent facelift is to be performed, also predict the amount of produced lateral orbital skin excess and the need for an excision of a lateral wedge beneath the sideburn to avoid raising the hair-bearing skin too much. This is particularly important in the female patient.
In the male patient, the height of the brow should be approximately level with the supraorbital rim. In females, personal desires more often enter into planning the shape and height of the brow. [5] Some patients desire a more exaggerated look, although currently, most desire a relatively low central brow (at the level of the orbital rim) with a relatively straight rise to a lateral margin well above the orbital rim. Computer imaging is helpful in determining the patient's wishes preoperatively.
Ascertain the extent of action of the corrugator supercilii muscle, since many patients have extensive insertions into the skin, almost to the mid brow.
The shape and positioning of the incision in a coronal lift is important. Even if the scar is a hairline in width (1-2 mm), if it is positioned laterally too far anteriorly (directly above the anterior ear, as is depicted classically), the scar is visible whenever the hair is wet or the wind blows. This is because the hair growth naturally changes direction at that point. Position the scar posterior to this, preferably near the posterior margin of the ear. This increases the technical difficulty of elevating the coronal flap but the scar is almost imperceptible.
Map the route of the incision and subsequent scar across the top of the head for each patient. In patients with temporal hair recession, the incision can progress forward to cross the hairline and then return to the top of the head. The point of maximum skin resection then occurs on the hairless skin of the forehead and the hair-bearing skin to be advanced. In addition, a partial scar at the hairline is much less perceptible than one along its entire length, even if made uneven or in the form of a W-plasty.
In select patients, the incision can be made in other places, namely within the crease of a deep transverse rhytide of the forehead (mainly in male patients) or in the suprabrow area. This latter area tends to leave prominent scars, and its use is discouraged.
The controversy of endoscopic brow lifts compared to the classic coronal lift is discussed in Future and Controversies. [6, 7] The longevity of the lift produced by the endobrow procedure and the ability to completely remove the corrugator supercilii muscle through that approach are in question. It is useful in select individuals who should have minimal scarring or minimal lift and who do not mind undergoing repeat procedures in time. In individuals for whom it is imperative that sensation of the forehead not be altered, the endobrow procedure is an excellent option.
Preoperatively, shave the hair so that the final excision of skin results in hair-bearing skin juxtaposed to hair-bearing skin. Small adjustments can be made but the author prefers to perform this procedure since it is unwise to have areas of iatrogenic short hair away from the surgical scar.
The author has found that masking tape is an excellent means of controlling the posterior hair as long as it is removed prior to the patient fully awakening at the end of the procedure.
Make ringlets with the anterior hair and elastic bands. Remove these at the end of the procedure and even the hair once again, since necrosis has occurred when ringlets have pressed on the scalp within dressings after raising the flap.
Intraoperative Details
In the author's opinion, this procedure is best performed with the patient under general anesthesia. However, a combination of local anesthesia and an oral sedative has also frequently been used. [8] After routine induction, prepping, and draping, infiltrate the supraorbital, supratrochlear, and central brow areas with local anesthetic with epinephrine. Similarly infiltrate the anterior and posterior areas around the proposed incision site.
After waiting a few minutes to allow maximum epinephrine effect, make the incision at the posterior margin of the trimmed area.
Achieve hemostasis with judicious use of electrocautery on the posterior margin and freer use anteriorly. If desired, Raney clips may be used on the anterior margin, although they rarely are necessary.
Perform the supraperiosteal dissection sharply. The authors have found that sequential retraction with hooks on rubber bands affixed to a sterilely covered ether screen set at an appropriate angle allows for excellent visibility and aids with the dissection.
Spare the nerves and extend the dissection to the level of the brow. Completely free the tight attachments of skin in the suprabrow area, especially laterally. The dissection can be continued to the mid face in individuals who require midface elevation. If this is the situation, preserve the temporal branch of the facial nerve and the frontal branch of the deep temporal artery.
Once the brow has been dissected and the supratrochlear and supraorbital nerves are exposed, resect the corrugator supercilii muscles. Loupe magnification may be used for this portion of the procedure. Preserve the supratrochlear nerve as much as possible.
After muscle resection, resect the loose areolar tissue layer from the lateral scalp. The author usually places some of this to replace the removed muscle bulk. This results in a full appearance to the interbrow area.
Redrape the scalp flap and perform the excision with elevation of the preoperatively lower eyebrow first. D'Assumpcão measuring calipers greatly help in this process.
Resect the anterior flap appropriately and use hemostasis judiciously.
Close with deep sutures of 3-0 Vicryl placed so as not to strangulate hair follicles (which results in areas of alopecia). Final closure is with staples.
Apply a mildly compressive dressing with gauze padding behind the ears and on the incision line.
Postoperative Details
Postoperative care is minimal. Remove the dressings the day after surgery.
Generally, wash the patient's hair. Instruct the patient that he or she can bathe and wash normally. Bleaching and coloring agents should not be used for at least 3 weeks following the procedure.
Remove one half of the staples (mainly lateral and at the top of the head) 7 days postsurgery, and remove the remainder after 10-14 days.
Follow-up
Contact patients the night following the procedure if they are at home, or visit them in the hospital if that level of care is warranted. Observe them the next day and then every 3-4 days thereafter until all staples are removed.
Provide follow-up care weekly for 2-3 weeks, monthly for 2-3 months, and then every 6 months until 2 years postsurgery. When this level of follow-up care is provided, the number of repeat procedures is less than 2% over many years.
Complications
The most common complication is an area of relative insensitivity and paraesthesias for a few months following the procedure. The area immediately anterior to the scar can remain insensate, but this usually is of very little concern to the patient. Areas of alopecia can be addressed by simple excision if necessary. Asymmetry likewise can be corrected with simple re-elevation of the flap and correction of the lower side. The authors have found that almost a 4-to-1 correction is necessary in most individuals for elevation of the brow from so posterior an incision.
Blood loss of greater than 10-20 mL and the incidence of hematomas are unusual when general anesthesia is used and when the posterior flap is hemostatic throughout the remainder of the procedure. Infections are rare. In the uncomplicated or sole brow lift procedure, prophylactic antibiotics are not necessary.
The complications associated with midface lifting through lower eyelid incisions have been daunting. The worst is prolonged, severe, and irreparable ectropion. More conservative skin excision has helped, as has better fixation, but any vertical lift that relies upon the lower eyelid for support will generally fail. Midface lifting performed through brow lift incisions, with or without endoscopic assistance, has a lower complication rate and is generally preferred. Fixation to the temporalis fascia is generally acknowledged as the support that differentiates the procedure from lower eyelid procedures of the mid face. Midface lifting, in general, has a more prolonged recovery than brow lifting alone; this is usually manifested by prolonged edema.
Complications of treating the tear trough and nasojugal groove have mainly involved the irritation to the area through implants (Flowers) and permanent injectable agents such as silicone or Artecoll (a main stumbling block in its Food and Drug Administration approval process). The use of injectable agents based upon hydroxyapatite or hyaluronic acid is difficult in this area because of the thinness of the skin in the area. Even submuscular placement (beneath orbicularis oculi), which is preferred, can often result in visualization of the soft tissue filling agent. Sculptra is useful in the area, but granuloma formation and subsequent irregularity in contours has been a noted problem.
Outcome and Prognosis
The outcome for almost all patients is excellent and long-lived. The incision rarely is a concern, and hairdressers and beauticians often comment that it is excellent. The procedure rarely needs to be repeated, even after 20 or more years, because elevation is performed during the procedure and loose areolar tissue is removed, stopping descent of the brow with gravity and aging. The smoothness of the central brow region is difficult to achieve with any other procedure. See the images below.
Preoperative photograph of patient prior to a brow lift performed through the coronal approach.
Postoperative photograph demonstrating marked improvement in the periorbital area after a brow lift performed through the coronal approach.
Preoperative photograph demonstrating a young female patient with marked frown lines and congested appearance of the interbrow area with marked brow ptosis.
Postoperative photograph demonstrating a young female patient who had marked frown lines and congested appearance of the interbrow area with marked brow ptosis, after only a brow lift with corrugator supercilii muscle resection performed through a posterior coronal approach.
Preoperative view of a patient with brow ptosis, marked actinic skin damage, and thin upper lip.
Patient who had brow ptosis, marked actinic skin damage, and thin upper lip. Postoperative (1 wk) view after brow lift with corrugator muscle resection, full-face carbon dioxide laser resurfacing, and upper lip augmentation using autologous tissue.
Future and Controversies
Currently, the largest controversy is the move to the endoscopic approach for the lift procedure. [6] As mentioned previously, unless fixation is improved, the necessity of repeating the procedure and the inability to completely remove the corrugator supercilii muscle do not outweigh the problems with paraesthesia and anesthesia of the area and the scar. In all but a select few patients with severe baldness, the endoscopic approach offers little advantage to the open approach.
In the future, with better fixation, means to remove the loose areolar layer, and means of efficient visualization and cautery of the area of the corrugator muscle, the endoscopic approach may become the procedure of choice. A report of the use of an endoscopic handpiece on the carbon dioxide laser for help with bloodless corrugator removal has been presented, but concern exists regarding the supratrochlear nerve, which is likely damaged by this application of laser energy. [9]
Laser procedures for nonresurfacing tightening of the skin also may help with correcting skin laxity in the periorbital region. More recently, both monopolar and bipolar radiofrequency tightening of the thin skin of this area has shown promise, particularly in the "crow's feet" area. The longevity, safety, and efficacy of these procedures are not yet definitively supported by peer-reviewed literature.
Injectable agents for nasojugal groove correction are not without complication. The use of agents that completely resorb with time is preferable to the unevenness that may occur with long-term or permanent implants. Fat grafting in the area is fraught with problems of uneven contour. If a lower eyelid bag is present, the transposition, redraping, or repositioning of fat into the nasojugal groove while still attached to a stalk supplying blood to the tissue can be an excellent means of rejuvenation of this area.
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Preoperative photograph of patient prior to a brow lift performed through the coronal approach.
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Preoperative photograph prior to brow lift, full facial laser resurfacing, and lip augmentation using autogenous tissue.
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Preoperative photograph prior to brow lift, full facial laser resurfacing, and lip augmentation using autogenous tissue. This photograph demonstrates the periorbital area. Note the heaviness of the upper eyelids.
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Postoperative photograph after brow lift, full facial laser resurfacing, and lip augmentation using autogenous tissue.
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Postoperative photograph after brow lift, full facial laser resurfacing, and lip augmentation using autogenous tissue. Note the reduction in upper eyelid skin redundancy even though no upper eyelid blepharoplasty was performed.
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Postoperative photograph demonstrating marked improvement in the periorbital area after a brow lift performed through the coronal approach.
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Preoperative photograph demonstrating a young female patient with marked frown lines and congested appearance of the interbrow area with marked brow ptosis.
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Postoperative photograph demonstrating a young female patient who had marked frown lines and congested appearance of the interbrow area with marked brow ptosis, after only a brow lift with corrugator supercilii muscle resection performed through a posterior coronal approach.
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Preoperative view of a patient with brow ptosis, marked actinic skin damage, and thin upper lip.
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Patient who had brow ptosis, marked actinic skin damage, and thin upper lip. Postoperative (1 wk) view after brow lift with corrugator muscle resection, full-face carbon dioxide laser resurfacing, and upper lip augmentation using autologous tissue.
